Will HL7 Create Payer/Provider Symbiosis?

The American Medical Association estimates that nearly $210 billion annually is spent to process healthcare claims. Moreover, approximately one in five medical claims are processed inaccurately, according to the AMA 2010 National Health Insurer Report Card. These processing errors cost an estimated $15.5 billion to the healthcare industry, and the report notes that if insurers could improve that number by just 1%, they would save nearly $777.6 million.

The pressure for both payers and providers to operate more efficiently and cooperatively is becoming a necessity for all concerned—which is why many in healthcare are using their Six Sigma and Lean initiatives to make the interaction between payers and providers a collaborative effort to decrease claims adjudication woes. But there’s more afoot that will help morph this traditionally adversarial relationship.

Though Lean and Six Sigma initiatives offer a path providers can take to improve the claim adjudication process, the Health Insurance Portability and Accountability Act may open up another avenue. Tom Hughes, President and CEO of Georgia-based Medical Electronic Attachment, Inc., and a member of the attachment committee of HL7 which is part of the HIPPA regulation.

The HL7 standard encompasses a range of operational, training, policy and technical issues. eXtensible Markup Language (XML) syntax is the basis for the HL7 Clinical Document Architecture Standard, and the attachment itself is carried inside the binary data segment of the X12N 275, or the 275 standard. This syntax standard is specifically designed for and by the healthcare industry to facilitate patient data exchange between computer applications and systems.

The attachments would work as follows, Hughes says, the payer sends a 277 to request the 275 information (using the payer control number as the method to link these), and the provider then sends the 275 in the same envelope with the 837 (using the provider assigned). The attachment committee’s goal is to help the industry establish a common language among computer applications regardless of platform, architecture, or programming. The committee is further defining a standard that will make payers and providers capable of sending and receiving detailed claims or encounter information such as diagnoses, test results, observations, treatment modalities, and so forth, in a specific HL7 format.

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